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1-888-586-4650
Preferred Medical Network Referral Form
Phone 1-888-586-4650 or Fax 502-489-5045
Please complete this entire form.
Items in red are
required
Patient Information
Name:
Sex:
M
F
Address:
Date of Birth:
City/State:
Date of Injury:
Zip Code:
Type of Injury:
Social Security #:
Claim #:
Telephone:
Employer/Group:
Carrier/Billing Information
Carrier Name:
Contact:
Address:
Telephone:
Ext:
City/State:
Zip Code:
Authorized Physicians
Physician #1:
City/State:
Telephone#:
Physician #2:
City/State:
Telephone#:
Authorized Services
Electrotherapy
:
Prescriptions
:
Maintenance Supplies
:
Purchase
Rental
TENS Purchase
Other Unit:
Home Delivery
Drug Card
30 Days
60 Days
90 Days
Indefinitely
Other:
TENS Supplies
Ostomy
Respiratory
In-Home Health
Other
Durable Medical Equipment
Wheelchair
Hospital Bed
Braces
CPM Machine
Bone Stimulator
Other:
Comments or Descriptions:
File Attachment:
Attach a digital copy of any documentation to this form. Microsoft Word, Plain Text, PDFs, JPEGs, TIFFs and GIFs accepted.
File size must be 2 MB or smaller
.
Please choose a file: